GULF MEDICAL JOURNAL GMJ, ASM 2012;1(S2):S61-S65

Acute tonsillitis in adults: The bacteriological profile and

antibiotic sensitivity pattern in Ajman, UAE
Meenu Cherian1*, Lisha Jenny John2, Jayadevan Sreedharan3, Tambi Abraham Cherian1
1
Department of ENT, Gulf Medical College, Hospital & Research Centre, Ajman, UAE
2
Department of Pharmacology, Gulf Medical University, Ajman, UAE
3
Research Division, Gulf Medical University, Ajman, UAE

*Presenting Author

ABSTRACT
Objective: The objective of this study was to determine the prevalence, pattern and
antibiotic sensitivity of acute tonsillitis.
Materials and Methods: A descriptive study was carried out from January 2011 to
December 2011among all adult patients attending the ENT outpatient department with
acute tonsillitis. The data wereretrieved from the medical records using a questionnaire.
Statistical analysis was carried out using SPSS.19 version.
Results: A total of 175 patients were included. The age ranged from 18 to 70 years. The
majority of the patients were Indian 49(20.6%), Emirati 35(14.7%), and Pakistani 31(13%).
The common clinical types of tonsillitis noted were acute parenchymatous / follicular /
exudative tonsillitis and acute pharyngotonsillitis. The highest frequency of acute tonsillitis
was observed in 2029 year age group with the commonest symptoms at presentation being
sore throat and fever. The tonsils on examination were enlarged in more than half the
patients and follicles seen on the congested surface of both or one tonsil in a majority of the
patients included in the study. The relative frequency of presentation was high in the
summer months from Marchto September. About one fourth of the study group reported to
have had an episode of similar clinical presentation during the previous year. Among the
study participants whose throat swab cultures were done, Streptococcus was the commonest
species identified,a majority being alpha haemolytic streptococci, followed by streptococcus
pyogenes and streptococcus pneumoniae. Most of these organisms were sensitive to third or
fourth generation Cephalosporins and CoAmoxyclavulanic acid. The majority of patients
responded to treatment with oral or parenteral antibiotics of the above group. Some
organisms were multi-drug resistant, being sensitive only to piperacillin, ceftriaxone,
cefotaxime and meropenem.
Conclusion: Therapeutic guidelines for optimum clinical response to acute tonsillitis among
adult patients can be developed based on the common organisms grown on throat swab and
their antibiotic sensitivity pattern to reduce patient morbidity and provide cost effective
treatment.

Key words: clinicalprofile, adult acutetonsillitis, microorganisms, antibacterial agents

INTRODUCTION many occasions2. Adult acute febrile

Acute infection of the tonsils is most
frequent in childhood in the age group of
5 to 15 years presumably because
immunity to common organisms has not
been established1. Initial viral infection
may predispose to super-infection with
bacteria, or viruses alone may be
responsible for tonsillitis in children on
suppurative tonsillitis is relatively
uncommon and the bacteriological
profile of adults with acute tonsillitis is
different from that of a child3. The
commonest pathogen in adult acute
tonsillitis was shown to be beta
hemolytic streptococci, as reported in a
study done on 257 young men in

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military service . Another study found
3
Haemophilus influenzae was the single
most common bacterium isolated from
the tonsil core in 262 patients in the 2-7
year old age group with recurrent
tonsillitis4. Anaerobic bacteria have been
implicated in adults with acute
tonsillitis, especially the ones with a
complication or with a predisposing
factor leading to compromised
immunity . 4,5
Acute tonsillitis where viruses like
adenovirus, Epstein Barrvirus or
influenza virus is implicated is treated
symptomatically with antipyretics,
antiinflammatory drugs and mouth
gargles;in case of secondary bacterial
infection causing purulent material to
accumulate in the tonsillar crypts,
penicillin has been the drug of choice6.
Presently penicillin treatment of
tonsillopharyngitis does not meet the
minimum United States Food and Drug
Administration standards for firstline
treatment, which is 85% or greater
eradication at the end of therapy. Recent
results with amoxicillin suggest its
efficacy is also waning. Cephalosporins
alone or cephalosporins with
metronidazole where anaerobes are
implicated have the highest bacteriologic
and clinical efficacy7.
Review of literature indicates that
many studies on bacteriological profile of
acute tonsillitis have been carried out
among children or a mixed population
with children and adults, but there are
very few studies that are confined to
acute tonsillitis in adults. Acute
follicular, acute exudative or acute
parenchymatous tonsillitis may require
admission due to the patients toxic and
dehydrated condition that leads to loss
of working hours. Hence, identification
of the organisms responsible and their
antibiotic sensitivity pattern can guide
in early and timely oral antibiotics to
GMJ, ASM 2012;1(S2):S61-S65
preventing wasting of hours of work in
hospital stay. The primary objective of
this study was to determine the
bacteriological profile and antibiotic
sensitivity pattern of the adult patients
with acute tonsillitis attending the ENT
outpatient department at GMC hospital
during a period of one year.
MATERIALS ANDMETHODS
A descriptive retrospective
epidemiological study design was
adopted in the present study. This study
was carried out among all adult (18
years and above) patients attending the
outpatient department (OPD) of ENT of
Gulf Medical College Hospital, Ajman
with acute tonsillitis from January 2011
to December 2011. The patients records
were obtained from the Medical Records
Division and the culture and sensitivity
reports were obtained from the central
laboratory.
A pilot-tested questionnaire was used to
evaluate the prevalence, pattern and
antibiotic sensitivity of acute tonsillitis.
The questionnaire included both
openended and close-ended questions.
Socio demographic characteristics (age,
gender, nationality of the patients),
clinical data (clinical diagnosis, clinical
manifestations of acute tonsillitis,
examination findings), and laboratory
data (CBC report, culture and sensitivity
report, organisms isolated, sensitivity
and resistance pattern) were recorded in
the questionnaire. The approval from the
Ethics Committee of Gulf Medical
University was obtained before the start
of the study. Statistical analysis was
carried out using SPSS.19 version.
Descriptive statistics were calculated.
RESULTS
A total of 175 patients (males:99,
females:76) were included. The ages
GULF MEDICAL JOURNAL GMJ, ASM 2012;1(S2):S61-S65
ranged from 18 to 70 years. The
majority of patients were Indians
[49(20.6%)], and the common clinical
types of tonsillitis noted were acute
follicular (Figure1), exudative (Figure 2)
and parenchymatous (Figure 3)
tonsillitis and acute pharyngotonsillitis.
The highest frequency of acute tonsillitis
(53.1%) was observed in 20-29 year age
group.

Figure 3. Acute parenchymatous tonsillitis

Table 1.Symptoms at the time of presentation

Presenting symptomsNo. %

Sore throat 149 85.1

Fever 109 62.3

Odynophagia 38 21.7

Body ache 29 16.6

Headache 26 14.9

Cough 23 13.1

Dysphagia 19 10.9
GMJ, 4th Annual Scientific Meeting of Gulf Medical University
62 Ear ache 16 9.1
Poster Proceedings 2012 www.gulfmedicaljournal.com
Figure 1.Acute follicular tonsillitis Nasal congestion 11 6.3

Cold 5 2.9
Nasal discharge 4 2.3
Voice problem 2 1.1
Neck swelling 1 0.6

Dizziness 1 0.6

Mouth breathing 1 0.6

Sneezing 1 0.6
Snoring 1 0.6

The commonest symptoms at

Figure 2. Acute exudative tonsillitis presentation were sore throat (85.1 %)
and fever (62.3 %) respectively. Details
are given in Table 1. The tonsils on
examination were enlarged in 80.6% of
patients (size 2+ or more) and follicles on
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GULF MEDICAL JOURNAL GMJ, ASM 2012;1(S2):S61-S65
the congested surface of one or both Among the study participants whose
tonsil was the commonest finding throat swab culture was done,
(94.4%). Streptococcus was the commonest
45.00 species identified
40.00 38.83 Figure 6.Organisms isolated on throat swab
35.00 35.62 35.45
30.00
culture
26.16 27.33
25.00 24.78
20.00 19.9520.51 (64.1%), a majority being alpha
16.31
haemolytic streptococci, followed by
15.00 15.36
10.00 9.65
5.00 5.56 streptococcus pyogenes and
0.00
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC streptococcus pneumoniae. 12.3%
were Neisseria species and a few
Figure 4.Seasonal pattern of tonsillitis staphylococcus species (Figure 6).
Most of the Streptococcus species
Figure 4 shows that there is an were sensitive to third or fourth
increase of cases of adult acute generation Cephalosporins and
tonsillitis presenting to the hospital CoAmoxy clavulanic acid. The
from March to September. About one majority of the patients responded to
fourth of the study group had similar treatment with oral or parenteral
episode(s) of clinical presentation in antibiotics of the above group. Some
the previous year. The details of organisms were multidrug resistant,
similar episodes are presented in being sensitive only to piperacillin,
Figure 5. ceftriaxone, cefotaxime and

meropenem.
2; 6%

6; 16%
DISCUSSION
Acute pharyngotonsillitis is
29; 78%
conventionally been known as the
clinical disease of the young, but in
our study we have noted 175 adult
One Two Three
patients of the same clinical condition
over a period of one year. The
Figure 5.Similar episode of Acute Tonsillitis in
incidence is 2% of all patients seen in
the last year
GULF MEDICAL JOURNAL
ENT out- patient department and
17%of all inpatients admitted in 2011.
The highest frequency has been noted
in the 20 to 29 year age group. The
commonest presentations that most
studies indicate, and our patients too
presented with, were fever and sore
throat6. Some of the patients did
present with symptoms suggestive of
an upper respiratory tract infection,
e.g. nasal congestion, malaise,
headache, etc. that probably indicates
a preceding viral upper respiratory
tract infection which was followed by
pharyngotonsillitis. Clinical
examination in most revealed enlarged
erythematous tonsils with follicles on
the surface of one or both faucial
tonsils. This is due to collection of
inspissated debris or purulent
material filling the many crypts on the
tonsillar surface, indicating a etiology at the outset with a secondary
probable bacterial etiology . 97.3% of
8
the patients also had tender unilateral
or bilateral cervical lymphadenopathy
which indicates an infective etiology6.
The maximum number of cases
presented in the summer months from
March to September. The reason for this
is not very clear as viral studies have not
been done to support the propensity of
certain common viruses in different
weather conditions. 78.9% of the cases
that came to us did not have similar
episodes in the previous year.
GMJ, 4th Annual Scientific Meeting of Gulf Medical University
64
Poster Proceedings
Out of the 175 patients only 106
underwent throat swab culture and
sensitivity. This was due the fact that
the patient had probably already
selfadministered some antibiotic, was
started on the same by a clinician of an
outside institution on an ambulatory
basis before the patient presented to us
or because of financial constraints.
Among those who underwent throat
GMJ, 4th Annual Scientific Meeting of Gulf Medical University Poster Proceedings
2012 www.gulfmedicaljournal.com
GMJ, ASM 2012;1(S2):S61-S65
swab culture and sensitivity more than
95% had significant bacterial growth.
Most of these patients were dehydrated
and toxic with high fever that required
admission and parenteral antibiotics.
The commonest organism grown was
alpha haemolytic streptococci followed
by beta haemolytic streptococi.
Alpha haemolytic streptococci are
considered to be commensals in the
throat6,8. Most of these organisms were
sensitive to third or fourth generation
Cephalosporins and Co-Amoxy
clavulanic acid. A trend towards
emerging multidrug resistant organisms,
sensitive only to piperacillin, ceftriaxone,
cefotaxime and meropenem, has been
noted.
Viral studies are not routinely
included in the diagnosis of acute
tonsillopharyngitis. Hence a viral
bacterial infection later could not be
proved.
The role of commensal bacteria in
acute tonsillitis needs further
elucidation. Either the commensals are
primary pathogens or secondary to viral
infections. The large number of isolates
of alphahemolytic streptococci with
significant growths on culture would
suggest an important role of these
organisms in the pathogenesis of acute
tonsillitis.
CONCLUSION
2012guidelines
Therapeutic www.gulfmedicaljournal.com
for optimum
clinical response to acute tonsillitis
among adult patients can be developed
based on the common organisms grown
on throat swab and their antibiotic
sensitivity pattern to reduce patient
morbidity and provide cost effective
treatment.
65
GULF MEDICAL JOURNAL GMJ, ASM 2012;1(S2):S61-S65
RECOMMENDATIONS differentiation. Scandinavian Journal of
Infectious diseases 1989;21:169-174. 4.
A follow up study needs to be
Gaffney RJ, Freeman DJ, Walsh MA, et al.
continued for a period of 5 years to Differences in tonsil core bacteriology in
understand and generalize the patient adults and children: a prospective study of
262 patients. Respiratory Medicine
profile and the clinical presentation and
1991;85:383388.
to develop therapeutic guidelines for
optimum clinical response to acute 5. Lodha R, Kabra SK and Jain N. Upper
respiratory tract infections. Indian J Pediatr 2001
tonsillitis among adult patients in the
Dec;68(12):1135-8. 6. Cowan DL And Hibbert J.
UAE. Acute and chronic infection of the pharynx and
tonsils, Scott Browns Otolaryngology. Sixth
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